Manager, Quality, Jackson Behavioral Health Hospital, Full-Time, Days
About The Position
The Manager, Quality, under the direction of the director of quality, develops, coordinates, implements, and evaluates continuous quality improvement activities for the quality program at Jackson Behavioral Health Hospital. The role facilitates and monitors patient safety activities, serves as a resource to the quality team, educates on best-practice standards of care, promotes continuous survey readiness, and reports quality indicators in department meetings. The manager leads the quality team on continuous quality improvement projects using approved tools, designed controls, and validations, while ensuring adherence to agency regulations. The position also supports the peer review process in collaboration with the Peer Review Committee Chairperson or designee, reviews referred cases and assigned mortality and morbidity cases, coordinates committee meetings, and maintains effective working relationships with Medical Staff leadership and departments across the facility.
Requirements
- Bachelor's degree in nursing or a healthcare field.
- Generally requires 3 to 5 years of related experience.
- A professional registered nurse license or another type of healthcare practitioner license is strongly preferred.
Nice To Haves
- Master's degree.
- Supervisory experience.
Responsibilities
- Analyze gaps and clinical barriers to care on an ongoing basis, collaborate with risk management on root cause analyses as needed, and align interventions with the organization's quality strategic plan.
- Oversee, coordinate, and implement regulatory activities and site reviews, including those required by AHCA/CMS, The Joint Commission, and other regulatory agencies.
- Implement facility quality improvement activities based on data and outcomes.
- Ensure departments understand and comply with the quality program, reporting elements, and regulatory requirements.
- Assist in designing and implementing quality and performance improvement projects, including valid and reliable indicators.
- Track, trend, interpret, and share quality outcomes data in real time, along with recommended follow-up plans and resolutions.
- Assist with staff participation in community outreach activities supporting quality and safety prevention initiatives.
- Coordinate, monitor, and evaluate medical record reviews and audits.
- Assist in updating, reviewing, and revising policies and procedures as needed.
- Develop strong working relationships with departments, divisional teams, and medical staff.
- Where applicable, assist with core-measure abstractions and keep current with changes to core-measure abstraction specifications.
- Facilitate all aspects of the peer review process under the direction of the director of quality and in collaboration with the Peer Review Committee Chairperson or designee.
- Maintain an effective working relationship with Medical Staff leadership and provide support related to the peer review process.
- Review cases referred for Peer Review.
- Coordinate Peer Review Committee meetings and related committee functions.
- Review assigned mortality and morbidity cases.
- Maintain unit PI Boards as needed.
- Perform tracers and prepare assigned units for continuous survey readiness.
- Role-model service excellence and CARE values: Compassion, Accountability, Respect, and Expertise.
- Perform other related job duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
